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<head>
    <meta charset="UTF-8">
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    <title>Document</title>

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<body>

    <div class="mainBox">

        <div id="main">
            <div class="top">
                <select>
                    <option>感染病例报告卡计</option>
                    <option>医疗医技异常事件</option>
                    <option selected>护理异常事件</option>
                    <option>输血不良反应</option>
                    <option>医疗器械异常事件</option>
                    <option>药物不良反应事件</option>
                    <option>异常用药事件</option>
                    <option>行政与后勤保障事件</option>
                    <option>治安管理异常事件</option>
                </select>
            </div>
            <div class="illustrate">
                <h4>填表说明</h4>
                <p>
                    1.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;暂存数据：保存填写的数据，下次可以进行补充修改，但是并没有提交。
                </p>
            </div>
            <div class="fill">
                <p>护理异常报告填写</p>
            </div>
            <div class="patient">
                <h4>患者基本情况&nbsp;&nbsp;<span class="oran">(不涉及患者,不填此项)</span></h4>
                <!-- 表单 -->
                <form class="fPatient firstForm">
                    <div class="div1">
                        <label class="lab1">病历号：</label>
                        <div class="line">
                            <input class="inp1 number" type="text" placeholder="请输入准确的病历号回车&nbsp;&nbsp;(门诊为就诊卡号)"><span class="span1"></span>
                        </div>
                    </div>

                    <div>
                        <label class="lab1">病人信息：</label>
                        <div class="line">
                            <label class="lab2">姓名</label>
                            <input class="inp2  nam" type="text"><span class="span2"></span>
                            <label class="lab2">性别</label>
                            <select class="slc1">
                                <option>男</option>
                                <option>女</option>
                            </select>

                            <label class="lab2">年龄</label>
                            <input class="inp3 age" type="number"><span class="span3"></span>
                        </div>
                    </div>

                    <div>
                        <label class="lab1">所在科室：</label>
                        <div class="line">
                            <select class="slc2">
                                <option>妇科</option>
                                <option>内分泌科</option>
                                <option>儿童心理科</option>
                                <option>儿科</option>
                                <option>产科</option>
                                <option>神经外科</option>
                                <option>眼科</option>
                            </select>
                        </div>
                    </div>

                    <div>
                        <label class="lab1">入院日期：</label>
                        <div class="line">
                            <input class="inp1" type="date" placeholder="请选择日期">
                        </div>
                    </div>

                    <div class="tBox">
                        <label class="lab1">临床诊断：</label>
                        <textarea class="txt"></textarea>
                    </div>
                </form>
                <h4>事件基本情况</h4>
                <!-- 表单 -->
                <form class="fPatient">
                    <div class="sure">
                        <label class="lab1">是否匿名上报：<span class="red">*</span></label>
                        <label class="lab3 radio-inline">
                            <input type="radio" type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"
                                checked>否
                        </label>
                        <label class="lab3 radio-inline">
                            <input type="radio" type="radio" name="inlineRadioOptions" id="inlineRadio1"
                                value="option2">是
                        </label>
                    </div>
                    <div class="sure">
                        <label class="lab1">事件发生日期：<span class="red">*</span></label>
                        <div class="line">
                            <input class="inp1" type="date" placeholder="请选择日期">
                        </div>
                    </div>

                    <div>
                        <label class="lab1">事件发生日期类型：</label>
                        <div class="line">
                            <select class="slc2">
                                <option>---请选择---</option>
                                <option>工作日</option>
                                <option>法定节假日</option>
                                <option>休息日</option>
                            </select>
                        </div>
                    </div>

                    <div class="sure2">
                        <label class="lab1">事件发生的场所：<span class="red2">*</span></label>
                        <label class="lab3  radio-inline">
                            <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option3" checked>门诊
                        </label>
                        <label class="lab3  radio-inline">
                            <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option4">急诊
                        </label>
                        <label class="lab3  radio-inline">
                            <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option5">住院
                        </label>
                        <div class="secLine">
                            <label class="lab4  radio-inline">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option6">手术麻醉
                            </label>
                            <label class="lab5  radio-inline">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option7">产房
                            </label>
                            <label class="lab5  radio-inline">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option8">医技科室
                            </label>
                        </div>

                        <div class="tirdLine">
                            <label class="lab6  radio-inline">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option6">公共活动区
                            </label>
                            <label class="lab4  radio-inline">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option7">场所不明
                            </label>
                            <label class="lab5  radio-inline">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option8">其他场所
                            </label>
                        </div>
                    </div>

                    <div>
                        <label class="lab1">事件发生的环境状态： </label>
                        <div class="line">
                            <select class="slc2">
                                <option>---请选择---</option>
                                <option>照明昏暗</option>
                                <option>地面湿滑</option>
                                <option>走廊拥挤</option>
                                <option>其他</option>
                            </select>
                        </div>
                    </div>

                    <div class="sure3">
                        <label class="lab1">事件发生前患者所处<br>的状态:(可多选)<span class="red3">*</span></label>
                        <label class="lab3 checkbox-inline">
                            <input type="checkbox" id="inlineCheckbox1" value="option1" checked>意识障碍
                        </label>
                        <label class="lab3 checkbox-inline">
                            <input type="checkbox" id="inlineCheckbox1" value="option2">听觉障碍
                        </label>
                        <label class="lab3 checkbox-inline">
                            <input type="checkbox" id="inlineCheckbox1" value="option3">视觉障碍
                        </label>
                        <label class="lab3 checkbox-inline">
                            <input type="checkbox" id="inlineCheckbox1" value="option4">语言障碍
                        </label>


                        <div class="seCheck">
                            <label class="lab3 checkbox-inline">
                                <input type="checkbox" id="inlineCheckbox1" value="option1">精神障碍
                            </label>
                            <label class="lab4 checkbox-inline">
                                <input type="checkbox" id="inlineCheckbox1" value="option2">肢体功能障碍
                            </label>
                            <label class="lab3 checkbox-inline">
                                <input type="checkbox" id="inlineCheckbox1" value="option3">感觉障碍
                            </label>
                            <label class="lab3 checkbox-inline">
                                <input type="checkbox" id="inlineCheckbox1" value="option4">特殊疾病障碍
                            </label>
                        </div>

                        <div class="seCheck">
                            <label class="lab3 checkbox-inline">
                                <input type="checkbox" id="inlineCheckbox1" value="option1">麻醉状态
                            </label>
                            <label class="lab7 checkbox-inline">
                                <input type="checkbox" id="inlineCheckbox1" value="option2">服用药物后
                            </label>
                            <label class="lab8 checkbox-inline">
                                <input type="checkbox" id="inlineCheckbox1" value="option3">治疗过程中
                            </label>
                            <label class="lab3 checkbox-inline">
                                <input type="checkbox" id="inlineCheckbox1" value="option4">公共服务设施
                            </label>
                        </div>
                    </div>

                    <div class="sure4">
                        <label class="lab1">事件经过：<span class="red4">*</span></label>
                        <textarea></textarea>
                    </div>


                    <label class="lab1">给患者造成损害的轻<br>重程度：</label>
                    <span class="bolder">Ⅰ级：发生错误，造成患者死亡</span>
                    <div class="mag">
                        <label class="lig">
                            <input type="radio" name="optionsRadios" id="optionsRadios1" value="option1">
                            I级：导致患者死亡
                        </label>
                    </div>

                    <span class="bolder mag">Ⅱ级：发生错误，且造成患者伤害</span>
                    <div class="mag">
                        <label class="lig">
                            <input type="radio" name="optionsRadios" id="optionsRadios1" value="option1">
                            E级：造成患者暂时性伤害，并需要进行治疗或干预
                        </label>
                        <label class="lig">
                            <input type="radio" name="optionsRadios" id="optionsRadios1" value="option1">
                            F级：造成患者暂时性伤害，并需要住院或延长住院时间
                        </label>
                        <label class="lig">
                            <input type="radio" name="optionsRadios" id="optionsRadios1" value="option1">
                            G级：造成患者永久性伤害
                        </label>
                        <label class="lig">
                            <input type="radio" name="optionsRadios" id="optionsRadios1" value="option1">
                            H级：导致患者需要治疗挽救生命
                        </label>
                    </div>

                    <span class="bolder mag">Ⅲ级：发生错误，但未造成患者伤害</span>
                    <div class="mag">
                        <label class="lig">
                            <input type="radio" name="optionsRadios" id="optionsRadios1" value="option1">
                            B级：发生但未累及患者
                        </label>
                        <label class="lig">
                            <input type="radio" name="optionsRadios" id="optionsRadios1" value="option1">
                            C级：累及到患者，但没有造成伤害
                        </label>
                        <label class="lig">
                            <input type="radio" name="optionsRadios" id="optionsRadios1" value="option1">
                            D级：累及到患者，需要进行监测以确保患者不被伤害，或需通过干预阻止伤害发生
                        </label>
                    </div>

                    <span class="bolder mag">Ⅳ级：错误未发生（错误隐患）</span>
                    <div class="mag">
                        <label class="lig">
                            <input type="radio" name="optionsRadios" id="optionsRadios1" value="option1">
                            A级：客观环境或条件可能引发不良事件（隐患）
                        </label>
                    </div>

                    <div class="E-category">
                        <label class="lab1">事件分类：<span class="red4">*</span></label>

                        <div class="cag">
                            <label class="lig">
                                <input type="radio" name="optionsRadios" id="optionsRadios1" value="option1">
                                <span class="bolder">警讯事件：</span>涉及死亡或严重身体伤害或心理伤害的意外事件。严重身体伤害具体包括丧失四肢或功能。
                            </label>
                            <label class="lig">
                                <input type="radio" name="optionsRadios" id="optionsRadios1" value="option1">
                                <span class="bolder">不良后果事件：</span>造成机体或功能的损害的事件。
                            </label>
                            <label class="lig">
                                <input type="radio" name="optionsRadios" id="optionsRadios1" value="option1">
                                <span class="bolder">未造成后果事件：</span>虽然发生了错误事实，但未造成不良后果。
                            </label>
                            <label class="lig">
                                <input type="radio" name="optionsRadios" id="optionsRadios1" value="option1">
                                <span class="bolder">临界差错事件：</span>任何发现的缺陷或错误，未形成事实，未造成危害，但其再发生很有可能带来严重后果。
                            </label>
                        </div>
                    </div>

                    <div class="E-subjects">
                        <label class="lab1">事件科目：<span class="red4">*</span></label>
                        <div class="sub">
                            <label class="radio-inline subChose">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1">护理处置事件
                            </label>
                            <label class="radio-inline subChose">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option2">导管事件
                            </label>
                            <br>
                            <label class="radio-inline subChose">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1">医技检查事件
                            </label>
                            <label class="radio-inline subChose">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option2">手术相关事件
                            </label>
                            <br>
                            <label class="radio-inline subChose">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1">护理处置事件
                            </label>
                            <label class="radio-inline subChose">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option2">导管事件
                            </label>
                            <br>
                            <label class="radio-inline subChose">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1">麻醉相关事件
                            </label>
                            <label class="radio-inline subChose">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option2">输血相关事件
                            </label>
                            <br>
                            <label class="radio-inline subChose">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1"
                                    value="option1">非预期事件<br>（重返事件）
                            </label>
                            <label class="radio-inline subChose">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option2">伤害事件
                            </label>
                            <br>
                            <label class="radio-inline subChose">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1">职业暴露事件
                            </label>
                            <label class="radio-inline subChose">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option2">信息异常事件
                            </label>
                            <br>
                            <label class="radio-inline lab2">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1">其他事件
                            </label>
                            <input type="text" class="t">
                        </div>
                    </div>

                    <div class="E-reason">
                        <label class="lab1">事件发生的原因<br>（可多选）：<span class="red5">*</span></label>
                        <div class="reason">
                            <label class="checkbox-inline reaChose">
                                <input type="checkbox" id="inlineCheckbox1" value="option1">确认/核查
                            </label>
                            <label class="checkbox-inline reaChose">
                                <input type="checkbox" id="inlineCheckbox1" value="option2">观察/评估
                            </label>
                            <br>
                            <label class="checkbox-inline reaChose">
                                <input type="checkbox" id="inlineCheckbox1" value="option3">诊断/判断
                            </label>
                            <label class="checkbox-inline reaChose">
                                <input type="checkbox" id="inlineCheckbox1" value="option4">知识/经验
                            </label>
                            <br>
                            <label class="checkbox-inline special">
                                <input type="checkbox" id="inlineCheckbox1" value="option5">技术/处置
                            </label>
                            <label class="radio-inline reaChose">
                                <input type="checkbox" id="inlineCheckbox1" value="option6">报告/汇报
                            </label>
                            <br>
                            <label class="checkbox-inline special">
                                <input type="checkbox" id="inlineCheckbox1" value="option7">病历等文书<br>记录
                            </label>
                            <label class="checkbox-inline reaChose">
                                <input type="checkbox" id="inlineCheckbox1" value="option8">沟通与知情<br>同意
                            </label>
                            <br>
                            <label class="checkbox-inline reaChose">
                                <input type="checkbox" id="inlineCheckbox1"
                                    value="option9">不作为&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
                            </label>
                            <label class="checkbox-inline reaChose">
                                <input type="checkbox" id="inlineCheckbox1" value="option10">宣教
                            </label>
                        </div>
                    </div>

                    <div class="aftermath">
                        <label class="lab1">不良后果：<span class="red6">*</span></label>
                        <select class="slc1">
                            <option>---请选择---</option>
                            <option>无</option>
                            <option>有</option>
                            <option>不详</option>
                        </select>
                    </div>
                    <div class="aftermath">
                        <label class="lab1">医疗纠纷：<span class="red6">*</span></label>
                        <select class="slc1">
                            <option>---请选择---</option>
                            <option>无</option>
                            <option>有</option>
                            <option>不详</option>
                        </select>
                    </div>
                </form>

                <h4>补救措施</h4>
                <form class="fPatient">
                    <div class="sure4">
                        <label class="lab1">事件经过：<span class="red4">*</span></label>
                        <textarea></textarea>
                    </div>
                </form>

                <h4>报告者基本情况</h4>
                <form class="fPatient">
                    <div class="reporter">

                        <label class="lab1">报告人信息：</label>
                        <label class="lab2">姓名<span class="red7">*</span></label>
                        <input class="inp2" type="text">

                        <label class="lab2">科室<span class="red7">*</span></label>
                        <select class="slc1">
                            <option>妇科</option>
                            <option>内分泌科</option>
                            <option>儿童心理科</option>
                            <option>儿科</option>
                            <option>产科</option>
                            <option>神经外科</option>
                            <option>眼科</option>
                        </select>

                        <label class="lab2">职称<span class="red7">*</span></label>
                        <select class="slc1">
                            <option>---请选择---</option>
                            <option>初级</option>
                            <option>中级</option>
                            <option>副高</option>
                            <option>高级</option>
                            <option>无</option>
                        </select>
                        <br>
                        <label class="lab1">联系信息：</label>
                        <div class="minority">
                            <label class="lab2">民族<span class="red7">*</span></label>
                            <input class="long" type="text">

                            <label class="lab2">职业<span class="red7">*</span></label>
                            <label class="radio-inline po">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio1" value="option1"> 医师
                            </label>
                            <label class="radio-inline">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio2" value="option2"> 药师
                            </label>
                            <label class="radio-inline">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio3" value="option3"> 护士
                            </label>
                            <label class="radio-inline">
                                <input type="radio" name="inlineRadioOptions" id="inlineRadio3" value="option3"> 其他
                            </label>
                            <br>

                            <div class="eml">
                                <label class="lab2">电子邮箱<span class="red7">*</span></label>
                                <input class="long" type="email">
                                <label class="lab2">签名<span class="red7">*</span></label>
                                <input class="long" type="text">
                            </div>
                        </div>

                        <br>

                        <div class="workBox">
                            <label class="lab1">单位信息：</label>
                        </div>
                        <div class="work">
                            <label class="lab2">单位名称</label>
                            <input class="long" type="email">
                            <label class="lab2">联系人</label>
                            <input class="mid1" type="text">
                        </div>
                        <div class="work2">
                            <label class="lab2">联系电话</label>
                            <input class="long" type="email">
                            <label class="lab2">报告日期</label>
                            <input class="mid2" type="date">
                        </div>
                    </div>
                </form>

                <div class="but">
                    <button class="sbm">确定提交</button>
                    <button class="save">暂存数据</button>
                </div>
                
            </div>
        </div>
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        <div class="modal-dialog" role="document">
          <div class="modal-content">
            <div class="modal-header">
              <button type="button" class="close" data-dismiss="modal" aria-label="Close"><span
                  aria-hidden="true">&times;</span></button>
              
            </div>
            <div class="modal-body">
              <p>提交成功</p>
            </div>
            <div class="modal-footer">
              <button type="button" class="btn btn-default" data-dismiss="modal">确定</button>
            </div>
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                  aria-hidden="true">&times;</span></button>
             
            </div>
            <div class="modal-body">
              
                <p>输入信息错误</p>
              
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            <div class="modal-footer">
              <button type="button" class="btn btn-default" data-dismiss="modal">ok</button>
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